Information memos

Numbered memos

Subscribe for email notification of each new memo

DDES INFO MEMO 2004-03
Appendix A

Acrobat version of DDES Info Memo 2004-03

Madison, WI – May 4, 2004

FACTS SPECIFIC TO ELDER SEXUAL ABUSE

Sexual activity that occurs under the following conditions is assaultive or abusive*:

• A person is physically forced into contact.

• A person is threatened, manipulated and/or tricked into contact.

• A person is unable to consent to sexual activity.

• An owner or employee of certain residential facilities has sexual contact or sexual intercourse with a person receiving services from that facility.**

*Ramsey-Klawsnik, Holly. Widening The Circle: Sexual Assault/Abuse and People with Disabilities and the Elderly, 1998, Chapter 3, p. 10. (Wisconsin Coalition Against Sexual Assault, Madison, WI)
**Section 940.225(2)(g), Wis. Stats. In addition, Section 940.225, Wis. Stats. applies to certain programs and facilities and makes it a crime for a person in charge of or employed by the program or facility to intentionally, recklessly, negligently abuse a patient or resident of the program or facility regardless of whether injury or harm occurred. It also makes it a crime for any person in charge of or employed by the covered programs or facilities to knowingly permit another person to intentionally, recklessly, or negligently abuse a patient or resident of the program or facility, again regardless of whether injury or harm occurred. "Abuse" as defined in s. 940.295, Wis. Stats., includes conduct which is not necessary for the treatment or maintenance of order and discipline of a facility or program and which harms, intimidates, humiliates, threatens, frightens, or otherwise harasses the patient or resident.

A range of behavior may be involved in the sexual assault***:

• Hands-off offenses include exhibitionism; voyeuristic activity; forcing an individual to view pornographic materials; sexual harassment and threats.

• Hands-on offenses include kissing, touching/molesting breasts, genitals, and buttocks; oral/genital contact; penetration of vagina or rectum with penis, fingers or objects.

• Harmful genital practices involve unwarranted, intrusive, and/or painful procedures in caring of genitals or rectal area. This includes applications or insertion of creams, ointments, thermometers, enemas, catheters, fingers, soap, washcloths, or other objects when not medically prescribed and unnecessary for the health and well being of the individual. The practices meet the idiosyncratic needs of the offender, but not the health or hygiene needs of the victims. Perpetrators may appear obsessed with the behavior, claim that the harmful practices are required for health or hygiene reasons, and be reluctant to stop when instructed to by health care professionals. These practices may co-occur with hands-off and hands-on offenses as described above. Individuals with disabilities that render them unable to independently bathe, use the toilet, and attend to other personal needs are vulnerable to these practices.

***Ramsey-Klawsnik, Holly. Widening The Circle: Sexual Assault/Abuse and People with Disabilities and the Elderly, 1998, Chapter 3, p. 10. (Wisconsin Coalition Against Sexual Assault, Madison, WI)

Elder sexual assault victims are individuals age 60 and older, or who are subject to the infirmities of aging.**** While the majority of identified abuse and/or sexual assault victims are female, males with special needs are also vulnerable. Some elder victims may be relatively healthy, requiring brief recuperative stays in a facility, yet abused by a family member in that setting. Others may be long term residents who are frail or have physical impairments or cognitive limitations.

****Section 46.90 (1) (c), Wis. Stats.

WHY ARE ELDERS VULNERABLE TO SEXUAL ASSAULT?

Individuals perceived to be particularly vulnerable, or a potentially easy target, are often chosen for victimization by sexual predators. Older individuals may fall into this category because of the following factors.

• Physical frailty or diminished ability to defend themselves
• Need for assistance from others (e.g., transportation, bathing, health care, etc.)
• Predictable routines, schedules
• Living alone or in a congregate setting
• Dementia or cognitive impairments

Adults are not necessarily less susceptible to sex crimes as they age. Sexual abuse is motivated not by sexual desire, but by a desire to exert power and control over others and to humiliate and belittle the victim. We may become more vulnerable to abuse as we age. Old age and impairment decrease personal power and thereby increase the risk of abuse. Consequently, elderly and disabled individuals are sexual abuse targets.

WHAT ARE INDICATORS OF SEXUAL ABUSE?

PHYSICAL SYMPTOMS*****

• Unexplained venereal disease or genital infections

• Vaginal or anal bleeding – injury to genital area

• Torn, stained, or bloody underclothing

• Difficulty sitting or walking

• Bruises or other signs of restraint

• Weight loss

*****"Sexual Abuse of Seniors" brochure (undated), Texas Association Against Sexual Assault, www.taasa.org

TIME AND LOCATION******

Exploitive sexual activity often occurs at a time or location unlikely to be selected by two consenting adults. For example, in a case involving a woman who was incontinent, an aide undressed her in the bathroom and left her seated on the toilet while the aide went to get a wash cloth and clean clothing. When the aide returned, she found a male resident standing in front of the woman. He had dropped his pants and was trying to force his penis in her mouth.

******"Elder Sexual Abuse Perpetrated by Residents in Care Settings." Holly Ramsey-Klawsnik, Victimization of the Elderly and Disabled, March/April 2004, p.94.

POWER DIFFERENTIAL*******

The offender often has significantly greater ability than the victim does. While the victim and offender may both have a form of dementia, the victim’s cognitive capacity may be significantly more compromised than that of the offender. For example, a perpetrator was verbal, ambulatory, and independent in eating and toileting. In contrast, his victim was quite passive and required assistance with all activities of daily living. The power differential may be physical, rather than cognitive. For example, a male resident walked into the room of a nonambulatory female, closed the door and molested her while she sat in her wheelchair, unable to remove herself from the situation.

*******Ibid

NOTICEABLE AVOIDANCE OF A SPECIFIC RESIDENT********

A dynamic observed in many cases of resident sexual assault is one man demonstrating inappropriate desire toward multiple women. He may approach numerous women and attempt to force unwanted sexual contact. These attempts may not be limited to residents but involve female staff and visitors as well. For example, a male resident, described as big and strong, became sexually aggressive toward staff and residents. This resident continued to grope at the breasts and peri-area of any female within reach. In addition, the resident would make sexual gestures with his tongue. One charge nurse stated her breasts were black and blue from this resident. When the facility tried using a male CNA, the nursing assistant stated he had never been groped so much in his life.

********Ibid

YES. Sexual assault can occur when someone is fully clothed. Examples include: manipulation of breasts while the individual is wearing a blouse and bra and the probing of the genital area while the individual is wearing underwear under her nightgown. A "hands-off" example would be forcing a fully clothed individual to witness the perpetrator masturbating, while making sexual comments such as "you know how bad you want it."

Background

In order to not be considered abusive, sexual contact can only occur between consenting adults. Elements of consent********* would include:

• Individual understands sexual nature of conduct
• Individual understands that the body is private and one has the right to not consent
• Individual understands consequences of sexual activity (e.g., risk of sexually transmitted diseases)
• Individual understands consequences of social taboos and societal responses

*********Based on the Wisconsin Coalition Against Sexual Assault (Madison, WI) analysis of the case State v. Smith, 215 Wis.2d 84 (Ct. App. 1998)

Case Example

Sometimes the ability to discern the element of consent can be quite challenging. Invariably, the following is one of the scenarios raised when facility staff ponder the application of consent:

"Married couple lives together in a nursing home. They actually share a room. Both have dementia and have been adjudicated incompetent. While it is firmly believed that neither can consent to sexual activity, they do indeed have sexual contact with each other – a continuation of a happy, married life together for some many years. It appears both individuals enjoy the contact, are seen holding hands together at socials, and always seek each other out"

Guidance Sought

As staff of the facility, you are aware of the sexual contact. What are you to do? Is this a criminal justice issue, a BQA enforcement issue and/or a facility staffing issue?

Response by DHS

The individuals appear to be happy with the contact they have with each other even though they may not be viewed as capable of giving knowing consent. The quality of life for this couple is better because they are still a couple. By "seeking each other out" they seem aware of this despite their dementia. While there would be no criminal justice or regulatory enforcement response required in the situation described above, the facility would want to make sure that the respective guardians are aware of the sexual activity. It is suggested that the facility closely monitor the individuals' reactions. Document in their respective chart observations of the couple’s behaviors. If there's a change – e.g., one appears to be bothered by the contact or there are indications of force used by one or another or non-consent/cooperation, then facility staff should intervene. This may include re-contacting the respective guardians and/or contacting the regional ombudsman program or county adult protective services agency for assistance in developing a victim safety plan and a care plan for the offender.

It is important to note the response is not based on the fact that they are a married couple and the role of husband and wife includes being sexually involved. Rather, it is based on the facts that the couple appears very loving, they seek each other out, and they seem to always be happy in each other’s presence.

An example of sexual activity involving a married couple where staff acted inappropriately follows:

"A caregiver was discovered ‘assisting’ the sexual contact between husband and wife in a facility. Neither was aware of what was happening nor were they capable of consenting. She placed their hands on each other. She undressed each of them."

In this case, this was a sexual assault by the caregiver who disguised her conduct as "assisting the couple to enjoy each other". Subsequently, a hearing was held and the caregiver’s name was placed on the Caregiver Misconduct Registry.

Summary Statement

Because the issue of consensual sex can become extremely complicated when involving individuals who have diminished capacity, it is recommended that when such a situation is identified, that advice be sought from others on how to best proceed. Studies have shown that decisions made by groups are more effective than those made by individuals when no one person has the solution, but each person can contribute to a solution. Given the complexity of these cases, and the fact that there are often gaps in the services needed to assist victims, a broad range of professionals looking at a case and planning possible interventions is more likely to arrive at effective results. Therefore, if your entity is seeking guidance on how to proceed with a case of possible sexual assault, call your county’s lead elder abuse agency contact and if timely, ask to be placed on the next Elder Abuse Interdisciplinary Team (I-team) meeting for a discussion of the situation. You may also choose to consult with staff from the Bureau of Quality Assurance (BQA) (caregiver_intake@wisconsin.gov or 608-243-2019) or an ombudsman with the Board on Aging and Long Term Care (http://longtermcare.state.wi.us/home/).

While all intimate relationships have conflicts, an abusive power and control dynamic characterize abusive relationships. In an abusive relationship, one party fears the other and attempts to comply with the other's wishes to avoid the consequences of confrontation. Forms of domestic violence include, but are not limited to, physical, sexual, verbal and emotional abuse as well as financial exploitation. Often it is a combination of one or more of these types of abuse. It is important to understand domestic violence as a pattern of assaultive and coercive behaviors, designed to control another person. Abusers believe they are entitled to use any method necessary (e.g., use of threats and intimidation) to control how the victim thinks, feels and behaves. Abuse in later life can occur wherever the victim resides, which can include one’s own home in the community or a residential care facility. When the abuser is a family member, spouse or trusted caregiver, it is likely the victim will want to maintain the relationship while ending the abusive behavior.

**********Wisconsin Coalition Against Domestic Violence (Madison, WI) website: http://www.wcadv.org/gethelp (May 2004) and the National Clearinghouse on Abuse in Later Life (Madison, WI) website: http://www.ncall.us/#Definitions (May 2004).

Abuse in later life happens to people of all genders. Nationally reported cases of elder abuse indicate that about two-thirds of the victims are women, while one-third of the victims are men. While domestic violence programs in Wisconsin primarily serve women of all ages, many interventions such as safety plans, protective restraining orders and one-on-one counseling are useful and available for older victims of all genders.

FACTS THAT APPLY TO BOTH DOMESTIC VIOLENCE IN LATER LIFE AND SEXUAL ASSAULT OF THE ELDERLY

Anyone. Perpetrators may be family members, residents, or others.***********

• Family member: (may take two forms i.e., (1) family member, or (2) spouse/partner.)

• Family members (non-spouse) can include a parent, child, or grandchild, sibling, aunt, uncle, cousin, niece or nephew.

• Spouses or partners can be abusive or sexually assault their mate. In some long-term relationships, the abuse may have been going on for 40, 50, even 60 years. In other situations, the relationship and abuse may be relatively new (generally following divorce or death of previous spouse). Sometimes onset of abuse may occur during older years due to medical conditions, such as Alzheimer’s disease, that MAY manifest in violent or sexually inappropriate behavior.

• Resident-to-Resident abuse occurs in facility settings where a perpetrating resident forcibly (or in the absence of informed consent) engages in sexual contact or intercourse with another resident. The victim typically demonstrates decreased capacity in the areas of physical and/or mental health compared to the perpetrator.

• Caregivers may also be abusers. A caregiver is a professional, paraprofessional or volunteer providing services to an individual under a contractual or formal arrangement. This definition also includes "caregivers" as defined in Wisconsin law, section 50.065(1)(ag) 1., Wis. Stats.

• Others: Abuse may occur by persons who do not fit in the categories above. Sometimes these individuals are friends, neighbors or guardians of the victim. In these cases, the perpetrator is known and often has an ongoing relationship with the victim. In other cases, the perpetrator is a stranger. For example, a lay minister may visit residents at a nursing home but use this time as an opportunity to sexually prey on incompetent or frail elderly who may not be able to report the abuse.

***********Ramsey-Klawsnik, Holly. Widening The Circle: Sexual Assault/Abuse and People with Disabilities and the Elderly, 1998, Chapter 3, p. 11. (Wisconsin Coalition Against Sexual Assault, Madison, WI).

The majority of identified abusers and sexual offenders are male. Female physical abuse and sexual offending does occur, however, and allegations involving female perpetrators also require careful investigation and intervention. While traditionally a perpetrator of domestic abuse has been described as an "intimate partner" (e.g., spouse, life partner or significant other), more recently the list of possible abusers has been expanded (e.g., adult children, grandchildren, nieces, nephews as well as caregivers.)************ The expanded list of perpetrators acknowledges that older persons may have ongoing, trusting relationships with individuals they care about or love yet they are not physically intimate with.

************Wisconsin Coalition for Advocacy, Wisconsin Coalition Against Domestic Violence, Wisconsin Coalition Against Sexual Assault and IndependenceFirst. Cross Training Workbook: Violence Against Women with Disabilities. Madison, WI.: 2004, p.7.

WHAT ARE POTENTIAL PERPETRATOR BEHAVIORS?*************

• Minimizes or denies abuse has occurred and instead blames the victim for being clumsy or difficult
• Attempts to convince health care workers that the patient is incompetent or grossly confused
• Senior is kept in an overmedicated state
• Overly protective or controlling of a family member (e.g., refuses to allow the elder to be alone with visitors, declines to leave the room during an exam, treatment or personal cares)
• Controls most of the resident’s daily activities
• When visiting, either keeps door closed or frequently draws privacy curtain
• Wants to be present for all interviews
• Answers for the victim
• Overly attentive, acts loving and compassionate to victim in the professional’s presence
• Charming and friendly to health care workers or abusive to health care workers (e.g., I’ll call your supervisor" or "I’ll sue you.")
• Uses the system to their advantage or against the victim by knowing "their rights"

*************This material was adapted from the handbook, From a Web of Fear to a Community Safety Net: Cross Training on Abuse in Later Life, published by the Pennsylvania Coalition Against Domestic Violence in coordination with the Pennsylvania Department on Aging: Harrisburg ,PA., 2001, p. 17.

WHAT ARE VICTIM BEHAVIORS THAT MAY INDICATE ABUSE?**************

• Remaining silent when asked questions about the abusive/exploitative acts s/he were subjected too
• Looks to the abuser to answer questions
• Minimize and deny abuse occurs or takes the blame for the abuse (e.g., "If I had been on time when she came to pick me up for church services then this would not have happened.")
• Makes a statement like: "He won’t like that." or "I don’t think that will be allowed."
• Protecting the abuser – trying to avoid police intervention and the arrest of the abuser
• Asks worker to leave and/or refuses offer of service(s)
• Asks for help and then changes his/her mind
• Doesn’t follow through on "the plan"
• Sudden change in behavior
• Fear of being alone with caregiver(s) or family member(s)
• Confusion
• Depression
• Talks fondly of the abuser’s good qualities

**************Ibid., p. 18

WHAT ARE SOME REASONS THAT VICTIMS MAY NOT WANT TO REPORT ABUSE?***************

There are many reasons that victims may be hesitant to report situations of abuse or exploitation. Some victims of family violence may wish to continue their relationship with their abusive family member, hoping that the assaults will stop and the relationship continues. Many other elderly victims fear retaliation if they either disclose abuse or try to leave an abusive situation. Victims who have been abused/sexually assaulted by another resident may be embarrassed or ashamed to talk about what has happened. They may believe they are in some way to blame for the incident. Or they may be afraid that they will not be believed or somehow punished if they tell staff.

***************Abuse of the Elderly in Regulated Facilities: Report and Recommendations. Wisconsin Coalition Against Sexual Assault and Wisconsin Coalition Against Domestic Violence, Madison, WI: 2003, p. 20.

Many older adults have additional barriers to reporting the abuse and/or sexual assault that was committed against them. Some of these unique issues include:

• Generational values that instill strongly held beliefs among many older persons that negative issues involving the family should never be discussed. This belief constructs a barrier for many older persons who are assaulted/abused by family members.
• Conflicting feelings toward the perpetrator, if s/he is a family member.

• Lack of information and/or resources about abuse and/or sexual assault and the agencies that might provide services and support.

• Inability to communicate with someone other than the person committing the abuse and/or sexual assault due to isolation, fear or intimidation.

• Inability to communicate verbally due to illness or disability that prevents disclosure.

• Lack of awareness by the older person that what s/he is experiencing or has experienced is abuse and/or sexual assault.

• An attempt to disclose to someone that abuse and/or sexual assault is occurring is met with disbelief or is discounted by the listener because of the victim's age and/or frailty.

• Many older victims of sexual assault may be adult survivors of childhood abuse, so abuse in later life is treated with the same silence that they experienced as children.

Older adults, like anyone else, will be affected by the trauma of abuse. Everyone experiences trauma differently. Some people will be severely traumatized by their abuse while others may not outwardly appear to have any long-term impact. A "hands-off offense" can severely traumatize one person while a person who was forcibly raped may not seem to experience long-term traumatic affects. Even if the victim could not physically feel or appears to have no memory of the assault, s/he may still be traumatized.

****************To Live Without Fear and Violence: Sexual Assault and Domestic Abuse Against Older Individuals: Participant Manual and Model Protocols for Law Enforcement Responding to Sexual Assault and Domestic Abuse Against Older Individuals. Wisconsin Coalition Against Sexual Assault, Inc., Madison, WI., 2004, pages 41 and 42.

Abuse can cause harmful psychological, physical, and behavioral effects. If the abuse is left unaddressed, these affects can potentially be very long lasting and persistent for the individual. It is estimated that 3.5 million women 60 years of age and older are survivors of childhood sexual abuse (Farris and Gibson 1992). Below is a listing of both short-term and long-term effects that may indicate the presence of trauma.

-Anxiety -Persistent anxiety and fear

-Fear -Feelings of shame or guilt

-Anger -Low self-esteem

-Withdrawal -Emotional numbness

-Sexualized behavior -Relationship and sexual problem

-Nightmares or trouble sleeping -Sleep disturbances

-Acting out -Recurring flashbacks, nightmares, or intrusive thoughts

-Chronic stress and other health problems

-Drug and alcohol abuse

-Suicidal thoughts

-Self-injury

-Eating disorders

-Clinical depression

-Dissociative identity disorder

Older adults have usually developed a vast array of coping skills over their lifetimes. Service providers can assist a victim to recognize these coping skills, how they were applied in the past, and how they can be utilized to address the current situation. It should not be assumed that elderly victims of sexual assault displaying no psychological trauma are unharmed. Many factors determine whether or not internal distress will be openly displayed, including personality, history, cultural and religious background, psychosocial functioning, and cognitive ability.*****************

*****************"Elder Sexual Abuse Perpetrated by Residents in Care Settings." Holly Ramsey-Klawsnik, Victimization of the Elderly and Disabled, March/April 2004, p.93.

Asking questions about domestic violence and sexual assault in later life must always be done with great care and sensitivity. While it is recommended that entities screen all individuals who they serve concerning family violence within their first week of participation or residency, screening questions should continue to be asked periodically. It is believed that once rapport has been established questions may be asked in a more conversational manner.

Examples of indirect ways of asking about abuse, neglect and exploitation include:

• Tell me about who you normally see, volunteer or visit with during the week.
• Who do you especially look forward to seeing, visiting and/or volunteering with?
• Anyone you don’t enjoy as much?
• What would you do if someone made you mad? If they wanted you to do something you didn’t want to do?
• Do you think you are more assertive at your current age, or were you more assertive when you were younger?
• If you and your (spouse, son, daughter, nurse’s aide, physician, etc.) have a disagreement, who usually wins? How do they (you) win?

With more direct questions, prefacing them with a very direct statement would be best. For example, you may wish to start out as follows: "I’m going to ask you some questions about conduct that may be physical, financial or sexual abuse. These can be issues that people have in their lives, but in the past were not asked about. I’m asking about them now, because sometimes people are currently experiencing them, or abuse from the past is affecting how they feel presently."

Examples of direct questions****************** follow.

• Has any family member, resident or staff member ever physically harmed you? Have you been struck, slapped or kicked? Has your hair been pulled?
• Have you been tied down or locked in a room?
• Have you been threatened with punishment or deprived of things because you did not comply?
• Have you received the "silent treatment?" Have you been ignored?
• Has anyone touched you in a sexual way without your permission?
• Is money being stole from you or used inappropriately?
• Have you been forced to sign any legal documents (e.g., power of attorney for finances, will) against your wishes?
• Have you been forced to make purchases against your wishes?

******************

Adapted from: Elder Abuse. Laurel H. Krouse, MD, Paoli Memorial Hospital, Paoli, PA., eMedicine.com,inc. [Web address: http://emedicine.medscape.com/article/805727-overview#showall], June 5, 2001.

Follow-up questions (if abuse is identified):

• How long has the situation been occurring?
• Is it an isolated incident?
• When do you think the next episode may occur?
• Is the person who hurt/harmed you still present in the facility?
• What would you like to see happen?
• Have you ever received help for this problem before?

Convey to the patient that she/he does not deserve to be hurt or controlled (if abused) or that she/he has a right to be cared for with dignity and respect (if neglected).

Entities should notify local law enforcement authorities in any situation where there is a potential criminal violation of the law. Call the police without delay if someone is in immediate, life-threatening danger.

If the danger is not immediate, but you suspect that abuse has occurred or is occurring, please relay your concerns to the Bureau of Quality Assurance (BQA), the long-term care ombudsman program and/or law enforcement, as appropriate. You may also elect to connect with your county’s lead elder abuse agency contact person and if timely, ask to be placed on the next elder abuse interdisciplinary team (I-team) meeting for discussion of the situation. Otherwise, ask the I-team coordinator’s opinion on how to best proceed in gaining additional insight (some agencies have a core group that can be pulled together for emergent cases, others have an electronic message board for seeking advice).

The sexual assault or domestic violence program in your area can provide insight and possible advice as well. Calls to elder abuse, sexual assault and domestic violence agencies can occur in an anonymous fashion, i.e., there is not a need to provide identifying information specific to your organization or the resident you are concerned about.

Return to Info Memos Index